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Case Report

Management of a mandibular first


molar with three separate root canals
in the distal root
Kesavan Mohan, Sarra Abdulhamid Abdalla Ben Hmida, Saaid Ayesh Alshehadat,
Mohamad Syahrizal Halim, Hany Mohamed Aly Ahmed
Department of Conservative Dentistry, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

Address for correspondence: Dr. Hany Mohamed Aly Ahmed, Department of Conservative Dentistry, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian - 16150, Kelantan,
Malaysia. E-mail: hany_endodontist@hotmail.com

ABSTRACT

Adequate knowledge on the root canal morphology is essential for successful root canal treatment.
Mandibular molar teeth show considerable variations in their external and internal radicular morphology
that require special attention from dental practitioners to provide the best clinical outcomes for the patients.
The occurrence of three separate root canals in the distal root of a mandibular molar is uncommon. This
article aims to present the endodontic management of a mandibular first molar that has five separate
root canals (two root canals in the mesial roots and three root canals in the distal roots).

Keywords: Distal, endodontic treatment, mandibular molar, root canal, root canal morphology, root
canal treatment, three

INTRODUCTION
Sufficient knowledge on the root and root canal
morphology, good anticipation, and absolute clinical
thoroughness are fundamental prerequisites for a
successful root canal treatment. [1,2] This includes
preoperative awareness of, and intraoperative care to
identify, the landmarks of normal morphology as well
as any unusual anatomy of the root canal system.[3] A
meticulous understanding of the anatomical variations
will help to reduce the number of missed root canals
during treatment, thus increasing the rate of clinical
success.[3]
Studies have demonstrated wide anatomical variations
in the mesial and distal roots of mandibular molar teeth
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DOI:
10.4103/2321-4619.176021

22 Journal of Restorative Dentistry / Vol - 4 / Issue - 1 / Jan-Apr 2016

that are mainly influenced by ethnicity and age.[1,4,5] Canal


systems commonly seen within these roots are two or
three canals in the mesial root and one or two canals in
the distal root.[6,7] Nevertheless, the occurrence of three
root canals in the distal root has been reported, and
this can reach up to 3% depending on the population
studied.[5] Rarely will all canals have a separate foramen
when exiting the tooth structure.[5,7]
Here, we present endodontic management of a
mandibular left first molar with five separate canals, two
canals in the mesial root and three canals in the distal root
(type VIII root canal pattern - Vertuccis classification).[1]

CASE REPORT
A 19-year-old male patient was referred to the polyclinics
of the School of Dental Sciences, Universiti Sains
Malaysia, with the chief complaint of a dull pain on
the mandibular left side while chewing. The medical
history was noncontributory. The clinical examination
revealed a restored mandibular left first molar with slight
pain on percussion. There was no evidence of current
swelling or tooth mobility. Radiographically, the tooth
showed a periapical radiolucency around the mesial root

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Mohan, et al.: Management of a mandibular molar with a complex anatomy

[Figure1a]. The tooth was provisionally diagnosed as


necrotic with chronic apical periodontitis. After removal
of the restoration, the pulp was confirmed to be necrotic
and the endodontic treatment was commenced.
After rubber dam isolation, the access cavity preparation
was completed. Four root canals {two in the mesial
root [mesiobuccal (MB), mesiolingual (ML)], and two
in the distal root [distobuccal (DB), distolingual (DL)]}
were identified. The working length was determined
radiographically [Figure 1b], and with the aid of an
electronic apex locator (Root ZX, J Morita, USA). After
that, the canals were initially instrumented using SX
hand NiTi ProTaper file (Dentsply-Maillefer, Ballaigues,
Switzerland). For irrigation and lubrication, 2.5% NaOCl
and ethylenediaminetetraacetic acid (EDTA)-based root
canal conditioner (Glyde File Prep, Dentsply-Maillefer,
Ballaigues, Switzerland) were used. Subsequently, the
canals were filled with a nonsetting calcium hydroxide
paste (Henry Schein, New York, USA), and the tooth
was restored with a double seal composed of Caviton
(GC Corperation, Tokyo, Japan) capped with glass
ionomer cement (Fuji IV, Tokyo, Japan).
In the following visit and upon further exploration
between the distal canals using K-file size 10, a separate
third middle distal (MD) canal was identified [Figure
1c and d]. The mechanical instrumentation was continued
for MB, ML, DB, and DL canals using hand ProTaper files
up to size F3 and the MD canal was instrumented using
K-files up to size 30. The canals were then obturated
using lateral compaction technique [Figure 1e]. After
that, the occlusal and proximal cavities were restored
using a posterior resin composite restoration [Figure 1f].

DISCUSSION
The root canal anatomy shows considerable variations
and complexities that require special attention while
performing root canal therapy.[1,8] A comprehensive
understanding of common root canal configurations and
its variations is essential to achieve long-term success of
the root canal treatment.[8,9] Researchers[10] reported 42%
incidence of missed root/root canals in teeth scheduled
for retreatment. Therefore, complete debridement
followed by three-dimensional obturation of the root
canal system is an utmost important procedure in
endodontic practice.
The presentation of this case is to contribute to our
knowledge of the anatomical variability in mandibular
molars. This case demonstrates a rare anatomical
configuration, and supports previous reports of the
existence of root canal aberrations in the distal root of
mandibular molars. The distal root has three distinct root
canals with three portals of exit, which could be described

Figure 1: (a) Preoperative radiograph, (b) Working length determination


using periapical radiography, (c and d) Four canals were identified (Mb,
ML, DB, and DL) during initial exploration and upon further exploration,
a separate third MD canal was identified, (e) Obturation using lateral
compaction technique, and (f) Coronal restoration was done using a
posterior resin composite

as Type VIII canal configuration according to Vertuccis


classification.[1] Previous reports demonstrated other
root canal configurations such as Type XVIII according
to Sert and Bayirli supplemental configurations.[5,11,12]
The occasion of four canals in the distal root has also
been reported.[9,13]
Based on the discussion above, it appears that
ignoring the absolute confidence for the preestimated
number of roots/root canals is essential for practicing
endodontics.[14] Diagnostic measures are important
aids in locating root canals including the use of some
sort of magnification (operating microscope or loupes),
pretreatment radiographs with different horizontal
angulations, examination of the pulp chamber floor
with a sharp explorer, troughing the grooves with
ultrasonic tips, staining of chamber floor, visualizing
canal bleeding points, and tactile examination of the
root canal walls.[3,9,14-16] In some clinical situations, the
use of cone beam computed tomography (CBCT) is
helpful as an adjunctive diagnostic aid to conventional
radiography.[12]

CONCLUSION
The root canal anatomy in the distal root of mandibular
molar may show considerable variations. Therefore, it
is indispensable that dentists undertaking root canal
treatment in mandibular molars thoroughly assess the
root canal system in both the mesial and distal roots in
order to provide the best possible outcome of treatment
for the patient.
Journal of Restorative Dentistry / Vol - 4 / Issue - 1 / Jan-Apr 2016 23

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Mohan, et al.: Management of a mandibular molar with a complex anatomy

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How to cite this article: Mohan K, Ben Hmida SA, Alshehadat SA,
Halim MS, Ahmed HM. Management of a mandibular first molar with three
separate root canals in the distal root. J Res Dent 2016;4:22-4.
Source of Support: Nil, Conflicts of Intrest: The authors deny any
conflict of interest.